Basic Information
| Provider Information | |||||||||
| NPI: | 1518089507 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KARTHIKEYA DEVIREDDY MD INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | APEX MEDICAL GROUP INC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 311 W I ST | ||||||||
| Address2: | |||||||||
| City: | LOS BANOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936353479 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2098262222 | ||||||||
| FaxNumber: | 2098266554 | ||||||||
| Practice Location | |||||||||
| Address1: | 311 W I ST | ||||||||
| Address2: | |||||||||
| City: | LOS BANOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936353479 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2098262222 | ||||||||
| FaxNumber: | 2098266554 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2007 | ||||||||
| LastUpdateDate: | 04/06/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DEVIREDDY | ||||||||
| AuthorizedOfficialFirstName: | KARTHIKEYA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2098262222 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A96065 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | A95472 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | A90318 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | A35184 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | RHM08908F | 05 | CA | MEDICAID |